BH E2- Eating disorders

What is a disturbance of eating habits or weight control behavior that results in clinically significant impairment in physical health & psychosocial functioning?

Eating disorder

Who is more at risk for eating disorders, M or F?

Females

In what population do eating disorders have the highest mortality rate than any other disorder?

Women ages 15-24

What factors contribute to eating disorders?

Sociocultural: emphasis on thinness as ideal for beauty, role of media & peers, hx of illicit drug use

Psychological: FMH addictions, parental behaviors/attitudes, hx abuse/bullying

Biological: FMH mood disorders, depression, abnormalities in thyroid or hormones

What condition is characterized by persistent food restriction (self starvation) leading to significantly low body weight, an intense fear of weight gain & distorted body image?

Anorexia nervosa

What is the average age of onset of anorexia nervosa?

Females 13-18; males 12-13 (F > M)

What condition has the highest mortality rate of all mental disorders?

Anorexia nervosa

What are RF/precipitating factors for anorexia nervosa?

Perfectionism (failed attempts to lose wt), early puberty, antecedent illness w/ wt loss, athletics, FMH eating disorder, life & family stressors

Describe the psychological course/cycle of anorexia nervosa

Low self esteem → over eval of wt, shape, & eating → strict wt control behaviors & inc checking wt, shape, intake → dec in rate of wt loss → perceived as failure

The following criteria is for what condition?

• Restriction of energy intake below what is necessary to maintain healthy wt

• Intense fear of gaining weight or becoming fat, or persistent behavior that prevents wt gain despite being underweight

• Disturbed body image, weight or shape on self eval, or detail of seriousness of current low body wt

Anorexia nervosa

What subtype of anorexia nervosa?

• wt loss through diet, fasting, and/or excessive exercise

Restricting type

What subtype of anorexia nervosa?

• eating binges followed by self induced purging

• vomiting, laxatives, enemas, or diuretics

• some purge even after small amounts of food w/o binging

Bing-eating/purging type

The following behavioral signs are seen in what condition?

• relentless pursuit of thinness → exercise related rituals

• consistently complains of being fat, repetitive weighing

• obsessional preoccupation with food → prepares large meal then refuses to eat, prefers low calorie foods

• prefers to eat in private, eats small pieces of food

• laxative abuse

• low libido

Anorexia nervosa

What psychological signs can be seen in anorexia nervosa?

Social withdrawal, depression, low self esteem, restlessness or hyperactivity, poor sleep, signs of OCD personality (perfectionism)

The following PE findings can be seen in what condition?

• general/derm: low BMI, emaciation (BMI 17), hypothermia, dry scaly skin, lanugo hair growth, brittle hair/nails, hair loss

• HEENT: swollen parotid glands

• CV: bradycardia & hypotension

• Abd: hypoactive bowel sounds

• Gyn: amenorrhea, small ovaries, infertility

• MSK: muscle wasting, weakness, osteoporosis

Anorexia nervosa

What workup should be done for anorexia nervosa?

Vitals, ECG (long QTc & sinus brady), toxicology green, hormones (B-HCG, LH, FSH, prolactin, estradiol), bone density, CMP, vit D, elytes, etc

The following lab abnormalities can be seen in what condition?

• hypokalemia, hypocalcemia, hypophosphatemia, hypoglycemia

• hypercortisolemia

• metabolic alkalosis

• anemia/pancytopenia

• thyroid suppression

• dec FSH, LH

Anorexia nervosa

What is the treatment course of anorexia nervosa?

Determine level of care based on clinical presentation & BMI (inpatient vs outpatient), nutritional rehab & wt restoration, psychotherapy, & pharmacotherapy

What BMI is the minimal normal weight?

18.5 kg/m²

What BMI is considered mild anorexia nervosa?

17-18.49 kg/m²

What BMI is considered moderate anorexia nervosa?

16-16.99 kg/m²

What BMI is considered severe in anorexia nervosa?

15-15.99 kg/m²

What BMI is considered extreme in anorexia nervosa?

< 15 kg/m²

When should you consider inpatient admission in an anorexic patient?

<75% ideal body wt (BMI 13-14), hypothermia (<35.5C), bradycardia (<50 kids, <40 adults), orthostasis (drop sbp > 10, inc HR >35), K <2.5,

Dehydration, signs of multi organ failure, severe depression, SI or delirium

What is the first line treatment for inpatient management of anorexia nervosa?

Weight restoration (BMI > 18,5 or 85% IBW) → start caloric intake 1500-1800 kcal/day, then increase ever other day until 3500-400 kcal/day

What else is involved in the inpatient management of anorexia nervosa?

Monitor serum elytes (hypokalemia = vomiting), daily weight, fluid intake, & urine outputs

No bathroom privileges ~2 hrs after meals or with attendent

Stool softeners PRN (never laxatives), liquid food supplement, psychotherapy

What is a potentially fatal metabolic abnormality that results during nutritional rehabilitation of malnourished patients from electrolyte & fluid shifts?

Refreeding syndrome

What are signs of refeeding syndrome?

Dec levels of phosphorus (hallmark), hypoglycemia, arrhythmias, fluid retention (peripheral edema, CHF)

What psychotherapies can be used in the treatment of anorexia nervosa?

CBT (focuses on rethinking negative self talk/image, controls relapses), Family (maudsley method)& Nutritional counseling

What is the maudsley method?

Used in adolescents w/ anorexia nervosa → parents & nutritionists make meal decisions and eventual control of eating given back to pt

When can you consider discharge / outpatient treatment in a patient with anorexia nervosa?

Wt ≥85% IBW or BMI ≥ 16-17, medically stable, caloric intake 3500-4000 kcal/day, & responsive to psychological treatment

What are CIs to CBT?

Medical instabliity (HR < 30 BPM), SI, psychosis, substance use disorder

Why is pharmacotherapy not an initial or primary treatment in anorexia nervosa?

SEs such as weight gain or toxic levels 2nd to starvation status of patient or dehydration, which can cause seizures, bradycardia, hypotension, long QT, & heart rate variability

What RX options can be used as adjunct tx in anorexia nervosa for patients who do not gain weight despite initial treatment with rehabilitation & psychotherapy?

Fluoxetine, Olanxapine

What causes half of the deaths associated with anorexia nervosa?

Complications from starvation, suicide, or elyte imbalances

What are poor prognostic factors for anorexia nervosa?

> 7 years of illness (unlikely to fully recover), BMI < 14 at dx, older age of onset, binging & purging, comorbid anxiety or OCD< relationship difficulties, anxiety when eating with others

What condition is characterized by episodes of binge eating following by inappropriate ways of stopping weight gain?

Bulimia nervosa

What population is bulimia nervosa MC in?

W > M, ~18 y/o (20% of college women experience transient sx), Frequently occurs in normal weight young women

What etiology contributes to bulimia nervosa?

Hx sexual abuse, impulsivity, risk taking behaviors, self harm, personality disorders, depression/anxiety, societal & cultural pressures such as media

The following criteria is for what condition?

• recurrent episodes of binge eating

  • eating large amts of food w/in 2 hr period

  • lack of control when eating during episode

• recurrent inappropriate compensatory behavior to prevent wt gain (vomiting, laxative use(

• occurs at least once a week for 3 mos

• eval of self worth influenced by body shape & wt

• sx don’t occur during episodes of anorexia nervosa

Bulimia nervosa

What behavioral sx are seen in bulimia nervosa?

Extreme over concern with weight & shape, use of laxatives, diet pills & diuretics, compulsive exercise, eating large amounts of food then immediately going to the bathroom, mood swings, impulse control problems, excessive use of alcohol/drugs

Describe the psychological course of bulimia nervosa

Strict diet → tension & cravings → binge eats → purges to avoid weight gain → feels self hatred, shame, or disgust

What is Russell’s sign?

Calluses on hand (associated with bulimia nervosa)

What conditions may these PE findings be seen with?

• General: normal body habits, russel’s sign, self injury, petechia

• HEENT: persistent sore throat, halitosis, dry mouth, swollen parotid & salivary glands, erosion of dental enamel, cavities

• Cardio: peripheral edema, dizzy, tachycardia, palpitations, hypotension

• Abd: bloating, heartburn, hematemesis, C, D, malabsorption, rectal prolapse, pancreatitis

• Gyn: irregular cycle

Bulimia nervosa

What is the non-RX treatment for bulimia nervosa?

CBT (therapy of choice) & nutritional rehabilitation → establish parer of regular food intake, 3 meals a day + 2 snacks

What are the pharmacologic treatment options for bulimia nervosa?

1st line: fluoxetine

2nd line: sertraline, escitalopram

3rd line: topiramate (*use w/ caution, esp if low weight)

What meds are CI in bulimia nervosa treatment?

Bupropion → risk of seizures in pts w/ active sx

Paroxetine → inc risk of wt gain

What condition is characterized by episodes of binge eating WITHOUT use of compensatory behaviors after binging?

Binge eating disorder

What is the MC eating disorder?

Binge eating disorder

Who is binge eating disorder MC in?

F > M, onset adolescence or young adulthood

What is the etiology of binge eating disorder?

Childhood obesity, mood disorder, negative family/relationship dynamics, substance use disorder, low self esteem, societal pressures

The following criteria is for what condition?

• recurrent episodes of binge eating

  • large amounts of food w/in 2 hr period

  • lack of control overeating during episode

• ≥ 3 sx

  • eating faster than normal

  • eating until uncomfortably full

  • eating large amounts when not hungry

  • eating alone bc embarrassed

  • feelings of disgust, shame or guilt after eating

• marked distress ab episodes

• binge eating occurs atleast once a week for ≥ 3 mos

Binge eating disorder

What ssx are seen with binge eating disorder?

Extreme concern with weight/shape, feelings of ineffectiveness, low self esteem, frequently participates in new food/fad diets, hoards food, eats alone, keeps eating even when full, feels guilty/disgusted after overeating

Describe the psychological course of binge eating disorder

Over evaluation of wt → strict rigid diet → craves food → breaks diet → bignes → guilt, shame, self loathing → diets to regain control

What complications are seen from binge eating disorder?

Obesity, T2DM, HTN, inc cholesterol, gallbladder dz, sleep disorder, abnormal menstrual cycles, depression, anxiety, substance abuse disorder

What is the non pharmacological treatment for binge eating disorder?

CBT, interpersonal psychotherapy & lifestyle interventions (diet, exercise, nutrition education/modification), & treat comorbid disorders

What meds used to treat binge eating disorder can be used in high doses to reduce binge behavior short term & tx comorbids, but may cause weight gain?

SSRI → citalopram & fluoxetine

What drug used to treat binge eating disorder is an anticonvulsant / mild mood stabilizer that helps binge reduction and weight loss, but has increased adverse effects & discontinuation rates?

Topiramate

What is the only approve stimulant to treat binge eating disorder & helps with weight loss but has an increased risk of abuse?

*d/c if binge eating does not improve

Lisdexamfetamine (Vyvanse)